| NPI | 1912459058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.006604) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10002143A) |
| Enumeration Date | 2016-10-25 |
| Last Update Date | 2019-01-30 |