| NPI | 1528502358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11712) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001963) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-11712) | |
| Enumeration Date | 2016-12-13 |
| Last Update Date | 2021-12-06 |