| NPI | 1467867358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3474-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-005209) |
| Enumeration Date | 2014-06-30 |
| Last Update Date | 2014-12-19 |