| NPI | 1457786139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0010009) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0000250) |
| Enumeration Date | 2013-09-12 |
| Last Update Date | 2025-07-03 |