| NPI | 1174594873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07620) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-001823) |
| Enumeration Date | 2006-01-30 |
| Last Update Date | 2018-03-17 |