| NPI | 1568591261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 1617) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| 363A00000X Physician Assistant (Licence: SC 1617) | |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2025-11-14 |