| NPI | 1962028506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 0370759) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-06-19 |
| Last Update Date | 2022-10-03 |