| NPI | 1780654194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 001501) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 001501) |
| 363A00000X Physician Assistant (Licence: IL 085002028) | |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2014-04-29 |