| NPI | 1356897581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1174263) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MA PA100402) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 2000020732) | |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2025-10-14 |