| NPI | 1700302858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA066612) |
| Additional Taxonomies | 2083S0010X Preventive Medicine, Sports Medicine (Licence: PA RTRT005702) |
| Enumeration Date | 2017-08-21 |
| Last Update Date | 2025-08-01 |