| NPI | 1457896300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NY 027272) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant (Licence: NY 027272) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-01-02 |
| Last Update Date | 2025-07-16 |