| NPI | 1396746939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002771) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-000242) |
| Enumeration Date | 2005-08-04 |
| Last Update Date | 2023-11-09 |