| NPI | 1497084396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2019-0019) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085001767) |
| Enumeration Date | 2009-12-24 |
| Last Update Date | 2025-07-30 |