| NPI | 1023706744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085-009872) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2026006656) |
| Enumeration Date | 2023-05-01 |
| Last Update Date | 2026-08-19 |