| NPI | 1518901628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA054393) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT003024) |
| 363A00000X Physician Assistant (Licence: PA MA054393) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2019-11-22 |