| NPI | 1194887240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085003083) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10000909A) |
| 363AS0400X Physician Assistant, Surgical (Licence: IL 085-003083) | |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2020-12-01 |