| NPI | 1982251203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 083246) |
| Enumeration Date | 2019-08-21 |
| Last Update Date | 2024-05-24 |