| NPI | 1538152657 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085001633) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2001016022) |
| Enumeration Date | 2005-08-24 |
| Last Update Date | 2025-02-10 |