| NPI | 1417402793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 12732) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL4672) | |
| Enumeration Date | 2016-08-17 |
| Last Update Date | 2025-04-30 |