| NPI | 1164931960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.011631) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 003657-1) | |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2025-09-17 |