| NPI | 1649302233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15807) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 026576) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 030002067) | |
| 363A00000X Physician Assistant (Licence: NY 024438) | |
| Enumeration Date | 2007-03-10 |
| Last Update Date | 2022-10-10 |