| NPI | 1811090129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 3075) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-002802) |
| Enumeration Date | 2006-09-06 |
| Last Update Date | 2022-01-27 |