| NPI | 1558813394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2088) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA2088) |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA2088) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001728) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH 004998) | |
| Enumeration Date | 2016-10-27 |
| Last Update Date | 2025-08-26 |