| NPI | 1063066876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085009724) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601009239) |
| Enumeration Date | 2019-07-30 |
| Last Update Date | 2023-09-15 |