| NPI | 1235130543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 14666) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085-001096) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2007-08-13 |