| NPI | 1487085676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 024450) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 002702) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AZ 1134) | |
| Enumeration Date | 2013-12-12 |
| Last Update Date | 2023-01-30 |