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 |