| NPI | 1962049577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10413) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT002792) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2019-12-02 |
| Last Update Date | 2021-06-17 |