| NPI | 1225119167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IL 85002801) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001737) |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2018-04-19 |