| NPI | 1609260579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085008816) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11997) |
| Enumeration Date | 2015-03-27 |
| Last Update Date | 2022-06-06 |