| NPI | 1518939982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085006091) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 001335) |
| 363AS0400X Physician Assistant, Surgical (Licence: MN 10637) | |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2024-02-20 |