| NPI | 1770579666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NC 0010-06848) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-001759) |
| Enumeration Date | 2005-09-26 |
| Last Update Date | 2024-09-10 |