| NPI | 1225628191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11253) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.008145) |
| Enumeration Date | 2021-01-24 |
| Last Update Date | 2021-07-14 |