| NPI | 1386760742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085002940) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 85002940) |
| 363A00000X Physician Assistant (Licence: WI 5117-23) | |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2024-02-12 |