| NPI | 1386038917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA ML61070568) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-03-20 |
| Last Update Date | 2020-06-15 |