| NPI | 1841706538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7431377-1206) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: UT 7431377-4810) |
| Enumeration Date | 2017-12-18 |
| Last Update Date | 2025-10-02 |