| NPI | 1417178443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3058) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 350-039) |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2024-04-09 |