| NPI | 1740278191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1248) |
| Additional Taxonomies | 246ZX2200X Specialist/Technologist, Other, Orthopedic Assistant (Licence: 10-0627) |
| 363AM0700X Physician Assistant, Medical (Licence: 1248) | |
| 363AS0400X Physician Assistant, Surgical (Licence: 1248) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT8888) | |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2023-03-15 |