| NPI | 1679206296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085011301) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7946-23) |
| Enumeration Date | 2022-07-01 |
| Last Update Date | 2025-11-20 |