| NPI | 1649712894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 4461) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 001079) |
| Enumeration Date | 2016-11-04 |
| Last Update Date | 2019-06-05 |