| NPI | 1154671790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.004337) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10003478A) |
| Enumeration Date | 2012-09-11 |
| Last Update Date | 2022-03-31 |