| NPI | 1992102834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 385.007044) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096.003835) |
| Enumeration Date | 2014-11-20 |
| Last Update Date | 2023-01-19 |