| NPI | 1881669075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NE 2036) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085004591) |
| 363AM0700X Physician Assistant, Medical (Licence: MO 2003004599) | |
| Enumeration Date | 2006-02-21 |
| Last Update Date | 2018-04-30 |