| NPI | 1790765253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MN 1525) |
| 363A00000X Physician Assistant (Licence: WI 3855-23) | |
| Enumeration Date | 2006-01-20 |
| Last Update Date | 2016-08-09 |