| NPI | 1780242032 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 1502245) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: KS 50869) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2019-06-02 |
| Last Update Date | 2019-10-01 |