NPI | 1922482009 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9108971) |
Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL2688) |
363A00000X Physician Assistant (Licence: FL PAT9108971) | |
Enumeration Date | 2015-07-17 |
Last Update Date | 2022-04-14 |