| NPI | 1558781468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50006128RX) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: HI AT - 52) |
| Enumeration Date | 2014-04-17 |
| Last Update Date | 2019-09-12 |