| NPI | 1932733771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12227421-1206) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: UT BOC373277) |
| Enumeration Date | 2020-03-02 |
| Last Update Date | 2025-08-19 |