| NPI | 1992920110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 5822) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN AT0671) |
| Enumeration Date | 2007-04-14 |
| Last Update Date | 2018-12-20 |