| NPI | 1023261963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0004207) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 85.003263) |
| Enumeration Date | 2008-10-23 |
| Last Update Date | 2015-01-20 |