| NPI | 1699431056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085009829) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX Temporary) |
| Enumeration Date | 2021-11-10 |
| Last Update Date | 2023-09-25 |