| NPI | 1497965644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 174400000X Specialist (Licence: UT 7458969-4810) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2022-06-15 |