| NPI | 1700296381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8096767-1206) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 8096767-4810) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2014-05-05 |
| Last Update Date | 2021-08-25 |