| NPI | 1679978951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NV PA1748) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085005153) |
| Enumeration Date | 2014-10-29 |
| Last Update Date | 2021-10-20 |