| NPI | 1992051262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13904) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085004383) |
| 363AS0400X Physician Assistant, Surgical (Licence: IL 085004383) | |
| Enumeration Date | 2012-07-24 |
| Last Update Date | 2024-04-16 |