| NPI | 1871043620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 91276) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MT ATR-LAT-LIC-941) |
| Enumeration Date | 2016-10-05 |
| Last Update Date | 2024-04-05 |