| NPI | 1679540470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601005608) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085001941) |
| Enumeration Date | 2006-03-01 |
| Last Update Date | 2009-11-03 |