| NPI | 1518376243 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ND 533-14) |
| Enumeration Date | 2014-08-06 |
| Last Update Date | 2019-09-20 |