| NPI | 1629506753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TX PA17404) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT5781) |
| 363AM0700X Physician Assistant Medical | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-06-02 |
| Last Update Date | 2023-11-06 |