| NPI | 1154079721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085011000) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5894-23) |
| Enumeration Date | 2022-03-14 |
| Last Update Date | 2025-06-23 |