| NPI | 1689895690 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 001268) |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2013-10-27 |