| NPI | 1316223589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085004945) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096002713) |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2018-11-13 |