| NPI | 1003219619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085-005196) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 23-017858) |
| Enumeration Date | 2014-09-27 |
| Last Update Date | 2017-01-26 |