| NPI | 1609159607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1800) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085004143) |
| 363AM0700X Physician Assistant, Medical (Licence: SC 1800) | |
| Enumeration Date | 2011-09-26 |
| Last Update Date | 2015-12-01 |