| NPI | 1306335344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085010293) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096.005183) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2018-05-04 |
| Last Update Date | 2024-04-11 |