| NPI | 1356036644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 732923) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.009553) |
| Enumeration Date | 2023-04-11 |
| Last Update Date | 2024-02-28 |