| NPI | 1720476518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C07714) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0000699) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2014-12-31 |
| Last Update Date | 2023-05-09 |