| NPI | 1912308909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3067) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207XS0106X Orthopaedic Surgery, Hand Surgery (Licence: SC 3067) | |
| 363AS0400X Physician Assistant, Surgical (Licence: SC 3067) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2014-09-09 |
| Last Update Date | 2026-06-22 |