| NPI | 1811311822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 025180) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 002539) |
| Enumeration Date | 2014-02-11 |
| Last Update Date | 2021-09-21 |