| NPI | 1447360201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC 1183) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2013-02-25 |