| NPI | 1205942539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IL 085002765) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 2680-023) |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10000873A) | |
| Enumeration Date | 2006-08-21 |
| Last Update Date | 2021-12-17 |