| NPI | 1942571393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 2142) |
| Enumeration Date | 2012-01-17 |
| Last Update Date | 2019-07-15 |