| NPI | 1386794717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN pending) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: TN 3396) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 110102223) | |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2010-06-14 |