| NPI | 1578840658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7813419-1206) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 7813419-4810) |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2011-11-03 |
| Last Update Date | 2024-08-01 |