| NPI | 1386041739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024006271) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2014032022) |
| Enumeration Date | 2014-12-01 |
| Last Update Date | 2024-03-27 |