| NPI | 1962915777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14498) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT7943) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-11-15 |
| Last Update Date | 2024-09-05 |