| NPI | 1164052734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085009699) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005192) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA061396) | |
| Enumeration Date | 2020-01-22 |
| Last Update Date | 2023-07-12 |