| NPI | 1861575797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID PA918) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-268) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2020-09-09 |