| NPI | 1477955524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 3973) |
| Enumeration Date | 2014-09-19 |
| Last Update Date | 2020-03-24 |