| NPI | 1770966152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12946) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NC LAT-2699) |
| Enumeration Date | 2015-07-03 |
| Last Update Date | 2023-03-10 |