| NPI | 1427552702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0008672) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD 0000906) |
| Enumeration Date | 2018-03-21 |
| Last Update Date | 2022-11-04 |