| NPI | 1376075176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9791) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT002982) |
| Enumeration Date | 2017-03-30 |
| Last Update Date | 2020-06-14 |