| NPI | 1194716159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY PA856) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-002597) |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2024-08-08 |