| NPI | 1134749294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.008027) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: IL 085.008027) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-19 |
| Last Update Date | 2020-10-30 |