| NPI | 1083425243 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 125086259) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: MO 2025005124) | |
| Enumeration Date | 2025-01-16 |
| Last Update Date | 2025-07-08 |