| NPI | 1548394356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07882) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC 0712) |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2021-04-13 |