| NPI | 1326104910 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085000938) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 109142) |
| Enumeration Date | 2006-12-28 |
| Last Update Date | 2021-08-09 |