| NPI | 1609143270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9114483) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9114483) |
| 363AS0400X Physician Assistant, Surgical (Licence: IL 085004191) | |
| Enumeration Date | 2011-11-25 |
| Last Update Date | 2022-09-18 |