| NPI | 1558771543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085-005363) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601010096) |
| Enumeration Date | 2014-04-30 |
| Last Update Date | 2026-05-05 |