| NPI | 1679902084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 4341-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.004906) |
| Enumeration Date | 2013-11-06 |
| Last Update Date | 2022-10-21 |