| NPI | 1720294457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM 2001-PA38) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-002432) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2017-03-14 |