| NPI | 1053656298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024018875) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.004538) |
| Enumeration Date | 2012-11-28 |
| Last Update Date | 2024-06-12 |