Individual
ALLEN PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1800 W CHARLESTON BLVD, LAS VEGAS, NV 89102-2329
(815) 325-1699
Mailing address
236 W DAISY CIR, ROMEOVILLE, IL 60446-4972
(815) 325-1699
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
08/11/2016
Last updated
08/11/2016
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