| NPI | 1912035999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-903) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C04084) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-283) | |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2025-12-02 |