| NPI | 1497162994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10266) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 3533) |
| Enumeration Date | 2014-07-16 |
| Last Update Date | 2022-01-11 |