| NPI | 1407235500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MA PA7751) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A00504) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2020-09-22 |