| NPI | 1770833568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10167) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: RI AT00341) |
| Enumeration Date | 2012-09-19 |
| Last Update Date | 2021-05-07 |