| NPI | 1699016493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05029) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.004621) |
| Enumeration Date | 2013-03-05 |
| Last Update Date | 2014-07-03 |