| NPI | 1356826572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117089) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL4076) |
| Enumeration Date | 2018-10-03 |
| Last Update Date | 2023-02-14 |