| NPI | 1104396076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085-006788) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 4564) |
| Enumeration Date | 2018-12-04 |
| Last Update Date | 2021-04-26 |