| NPI | 1639560907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008846) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126001826) |
| 363A00000X Physician Assistant (Licence: NY 029349) | |
| Enumeration Date | 2015-02-09 |
| Last Update Date | 2024-11-12 |