| NPI | 1710024674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085002092) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4586) |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2022-01-11 |