| NPI | 1528462413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085007592) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant (Licence: MN 12524) | |
| Enumeration Date | 2014-10-21 |
| Last Update Date | 2023-01-13 |