| NPI | 1831735851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096004117) |
| Enumeration Date | 2019-11-25 |
| Last Update Date | 2024-08-06 |