| NPI | 1952704397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA15746) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126001471) |
| 363A00000X Physician Assistant (Licence: VA 0110007950) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-09-30 |
| Last Update Date | 2022-07-15 |