| NPI | 1366884769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC 2000014640) |
| Enumeration Date | 2013-07-25 |
| Last Update Date | 2021-05-06 |