| NPI | 1528461621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2016016570) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-005215) |
| Enumeration Date | 2014-10-02 |
| Last Update Date | 2016-06-16 |