| NPI | 1740373117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 3915) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL1436) |
| 363A00000X Physician Assistant (Licence: GA 006042) | |
| 363A00000X Physician Assistant (Licence: FL pa 9105450) | |
| Enumeration Date | 2006-09-30 |
| Last Update Date | 2024-04-23 |