| NPI | 1528319860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: VA 0101289626) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1368) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2026-07-13 |