| NPI | 1689172306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2018-01-28 |
| Last Update Date | 2022-09-18 |