| NPI | 1992028583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA5055) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363AS0400X Physician Assistant, Surgical (Licence: NH 1037) | |
| Enumeration Date | 2010-03-10 |
| Last Update Date | 2023-12-21 |