| NPI | 1366314254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 8871) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085.011659) |
| Enumeration Date | 2025-09-19 |
| Last Update Date | 2026-05-13 |