| NPI | 1114905411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.003370) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 010497) |
| 363A00000X Physician Assistant (Licence: WI 2095) | |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2016-10-04 |