| NPI | 1174950661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.004840) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10002688A) |
| 363AM0700X Physician Assistant, Medical (Licence: IL 085004840) | |
| Enumeration Date | 2013-09-30 |
| Last Update Date | 2019-03-22 |