| NPI | 1194177543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2016023821) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085006274) |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2018-11-27 |