| NPI | 1497257745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.006605) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005294) |
| Enumeration Date | 2018-03-02 |
| Last Update Date | 2019-11-22 |