| NPI | 1295947158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085003567) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12013) |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2018-05-29 |