| NPI | 1194771428 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1976) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-002426) |
| Enumeration Date | 2006-05-26 |
| Last Update Date | 2023-10-02 |