| NPI | 1285106096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL PENDING) |
| 363A00000X Physician Assistant (Licence: MI 5601008908) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA61094742) | |
| Enumeration Date | 2018-12-19 |
| Last Update Date | 2021-12-09 |