| NPI | 1730520529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085004803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NCCPA #1111137) |
| Enumeration Date | 2013-07-09 |
| Last Update Date | 2016-02-12 |