| NPI | 1104547173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9210) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.009077) |
| Enumeration Date | 2022-09-08 |
| Last Update Date | 2023-04-13 |