| NPI | 1548709082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2026006723) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2016022756) |
| Enumeration Date | 2017-02-16 |
| Last Update Date | 2026-03-18 |