| NPI | 1982140695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IN 10004423A) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36003150A) | |
| Enumeration Date | 2017-01-19 |
| Last Update Date | 2025-10-28 |