| NPI | 1336290360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105319) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9105319) |
| 363A00000X Physician Assistant (Licence: IL 85002260) | |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2021-01-06 |