| 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 |