| NPI | 1679089841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2000034938) | |
| Enumeration Date | 2017-12-22 |
| Last Update Date | 2025-05-29 |