NPI | 1912035999 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-903) |
Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-283) |
363AS0400X Physician Assistant, Surgical (Licence: MD C04084) | |
Enumeration Date | 2007-03-01 |
Last Update Date | 2019-12-04 |