| NPI | 1386637205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC 0010-15536) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.200030) |
| 363A00000X Physician Assistant (Licence: LA PA.CH0107) | |
| 363AM0700X Physician Assistant, Medical (Licence: LA PA.200030) | |
| Enumeration Date | 2005-08-25 |
| Last Update Date | 2025-10-03 |