| NPI | 1760408603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 107657) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-000958) |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2015-05-18 |