| NPI | 1477691582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA057347) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 001196) |
| 363A00000X Physician Assistant (Licence: DE C5-000679) | |
| 363A00000X Physician Assistant (Licence: MD C03530) | |
| Enumeration Date | 2007-02-01 |
| Last Update Date | 2025-10-07 |