| NPI | 1649550518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 002261) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-004833) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2011025935) | |
| Enumeration Date | 2011-08-24 |
| Last Update Date | 2024-01-03 |