| NPI | 1245388545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085003757) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096002321) |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2016-02-13 |