| NPI | 1508040312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IL 085000868) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50001371) |
| Enumeration Date | 2007-12-28 |
| Last Update Date | 2012-05-03 |