| NPI | 1619377363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant (Licence: FL 9114080) | |
| Enumeration Date | 2014-08-31 |
| Last Update Date | 2024-08-17 |