| NPI | 1497744338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1592) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 01567) |
| 363A00000X Physician Assistant (Licence: MA PA3909) | |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2018-03-29 |