| NPI | 1588223937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2025004718) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2021027374) |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2025-03-05 |