| NPI | 1407235500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 06532) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A00504) | |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA7751) | |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2024-09-26 |