| NPI | 1386179315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AL 1926) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 1977) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2017-04-27 |
| Last Update Date | 2022-04-01 |