| NPI | 1598036816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: LA 302676) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.200182) |
| 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: 11-0217) | |
| Enumeration Date | 2012-01-18 |
| Last Update Date | 2016-06-21 |