| NPI | 1871542811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085002238) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2005019359) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 2162) | |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2023-08-14 |