| NPI | 1932560224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0007572) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0000742) |
| Enumeration Date | 2016-03-14 |
| Last Update Date | 2020-12-03 |