| NPI | 1578125522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 207T00000X Neurological Surgery (Licence: GA 10208) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2019-06-30 |
| Last Update Date | 2021-06-10 |