| NPI | 1467928408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020030531) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.006912) |
| 363A00000X Physician Assistant (Licence: IA 126823) | |
| Enumeration Date | 2018-10-17 |
| Last Update Date | 2024-09-10 |