| NPI | 1902109267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.004809) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: 390200000X) |
| Enumeration Date | 2010-12-08 |
| Last Update Date | 2020-06-17 |