| NPI | 1184972994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085007217) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX pa03127) |
| Enumeration Date | 2012-08-28 |
| Last Update Date | 2023-09-21 |