| NPI | 1033766159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 7777) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085007226) |
| Enumeration Date | 2019-08-22 |
| Last Update Date | 2024-05-16 |