| NPI | 1427011568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ME PA1400) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: VT 104-0000105) |
| 363A00000X Physician Assistant (Licence: VT 055.0031165) | |
| Enumeration Date | 2006-04-10 |
| Last Update Date | 2023-10-06 |