| NPI | 1457494148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IL 085.002878) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1738) |
| Enumeration Date | 2007-02-14 |
| Last Update Date | 2011-11-17 |