| NPI | 1376941740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 2009) |
| Additional Taxonomies | 207PE0004X Emergency Medicine Emergency Medical Services (Licence: NH 30091) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NH 0555) | |
| Enumeration Date | 2014-12-16 |
| Last Update Date | 2023-05-04 |