| NPI | 1588781330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT000739) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2020-05-08 |