| NPI | 1851640452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114583) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: DE J3-0000431) |
| 363AM0700X Physician Assistant Medical | |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT005270) | |
| 363AM0700X Physician Assistant Medical (Licence: DE C5-0001003) | |
| Enumeration Date | 2012-08-29 |
| Last Update Date | 2022-01-05 |