| NPI | 1790986826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OK 2464) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OK AT233) |
| 363AS0400X Physician Assistant Surgical (Licence: OK 2464) | |
| Enumeration Date | 2007-05-29 |
| Last Update Date | 2014-12-22 |