| NPI | 1063040889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: OH 35C.000952) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036166902) |
| 207Q00000X Family Medicine (Licence: MN 75064) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2020-03-28 |
| Last Update Date | 2024-02-09 |