| NPI | 1043446008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 117199) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 385000318) |
| Enumeration Date | 2009-06-04 |
| Last Update Date | 2012-03-14 |