| NPI | 1649715434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 333701) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096004193) |
| Enumeration Date | 2017-01-03 |
| Last Update Date | 2022-10-12 |