| NPI | 1750757662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12428) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.005561) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-12428) | |
| Enumeration Date | 2015-08-14 |
| Last Update Date | 2023-03-03 |