| NPI | 1508164484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IN 71008226A) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36001848A) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 278-039) | |
| Enumeration Date | 2011-03-02 |
| Last Update Date | 2022-05-09 |