| NPI | 1285602847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2012013844) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096.002251) |
| 363A00000X Physician Assistant (Licence: IL 085004280) | |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2012-05-04 |