| NPI | 1982100699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SD 0700) |
| Enumeration Date | 2018-04-02 |
| Last Update Date | 2024-03-25 |