| NPI | 1194109454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 300317) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085005542) |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2022-02-04 |