| NPI | 1639571656 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2083) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NE 684) |
| Enumeration Date | 2014-09-22 |
| Last Update Date | 2019-04-16 |