| NPI | 1477219681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085009277) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2024011273) |
| Enumeration Date | 2021-11-11 |
| Last Update Date | 2024-10-07 |