| NPI | 1427185719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 3291) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 0000000826) |
| 363A00000X Physician Assistant (Licence: PA MA057282) | |
| Enumeration Date | 2007-02-27 |
| Last Update Date | 2022-07-20 |