| NPI | 1679351092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IL 085.011067) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 7630-23) |
| Enumeration Date | 2023-09-18 |
| Last Update Date | 2025-10-05 |