| NPI | 1376073981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2025007437) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2025007437) |
| Enumeration Date | 2017-06-15 |
| Last Update Date | 2025-06-16 |