| NPI | 1306065958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 224P00000X Prosthetist (Licence: IL 211000293) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096-002049) |
| 222Z00000X Orthotist (Licence: IL 213000217) | |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2016-03-20 |