| NPI | 1407034317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 52767) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: CA 070802371) |
| Enumeration Date | 2008-02-01 |
| Last Update Date | 2022-01-06 |