| NPI | 1619486818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011116) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT005209) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KY AT1494) | |
| Enumeration Date | 2017-09-20 |
| Last Update Date | 2024-11-05 |