| NPI | 1871012112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024006431) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-01245) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2017032699) | |
| Enumeration Date | 2017-09-19 |
| Last Update Date | 2024-02-27 |