| NPI | 1811273337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058194) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 164X00000X Licensed Vocational Nurse (Licence: TX 308769) | |
| 146N00000X Emergency Medical Technician, Basic | |
| Enumeration Date | 2011-10-28 |
| Last Update Date | 2016-04-26 |