| NPI | 1366529919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 2022) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 1056) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2016-08-30 |