NPI | 1619401718 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085009495) |
Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MI 6801098845) |
363AM0700X Physician Assistant, Medical (Licence: IL 085.009495) | |
Enumeration Date | 2017-04-14 |
Last Update Date | 2024-08-01 |