| NPI | 1750823860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3812 - 23) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1152) |
| Enumeration Date | 2016-11-08 |
| Last Update Date | 2023-07-12 |