| NPI | 1649715434 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA18914) | 
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096004193) | 
| 363A00000X Physician Assistant (Licence: LA 333701) | |
| Enumeration Date | 2017-01-03 | 
| Last Update Date | 2025-06-03 |