| NPI | 1922078955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085002970) |
| Enumeration Date | 2006-01-24 |
| Last Update Date | 2008-05-07 |