| NPI | 1669825295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 845) |
| 363A00000X Physician Assistant (Licence: OH 50.010263RX) | |
| Enumeration Date | 2016-07-19 |
| Last Update Date | 2026-05-14 |