| NPI | 1386977593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058371) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA 2000001831) |
| Enumeration Date | 2009-09-08 |
| Last Update Date | 2022-07-21 |