| NPI | 1548113376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2026007576) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.012208) |
| Enumeration Date | 2026-02-19 |
| Last Update Date | 2026-06-18 |