| NPI | 1922471036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085006597) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004531) |
| Enumeration Date | 2015-11-11 |
| Last Update Date | 2021-11-30 |