| NPI | 1982003174 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-02142) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 2400833) |
| Enumeration Date | 2014-08-14 |
| Last Update Date | 2025-02-07 |