is a Physician Assistant in , . practices all healthcare services and medical treatments related to Physician Assistant. The NPI Number for is 1629189238. The last update date is .
's current location address is , , . You can contact this provider via phone number . The mailing address for is , , . To know further, please read the information below!
Provider Profile Detail
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| Address | , , |
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| Sole Proprietor | -- |
| Credentials | -- |
NPI Number Detail
| NPI Number | 1629189238 |
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| Provider Enumeration Date | |
| Last Updated Date |
Provider Mailing Address Detail
| Address | |
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| City | |
| State | () |
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Provider's Primary Taxonomy Detail
| Speciality | Physician Assistant |
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| Taxonomy | 363A00000X |
| Licence No | 85002865 |
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Definition: A physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and is practicing within the scope of that license. Physician assistants are formally trained to perfor |
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Provider's Other Legacy Identifiers
| Identifier | Identifier Type | Identifier State | Identifier Issuer |
|---|---|---|---|
| 211448 | IL | MEDICARE GROUP NUMBER |
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