| NPI | 1508385659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085009125) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60909354) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60909354) | |
| Enumeration Date | 2017-09-10 |
| Last Update Date | 2022-12-12 |