| NPI | 1497240824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13435) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-13435) | |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2023-08-14 |