| NPI | 1710578117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085008197) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL pending) |
| Enumeration Date | 2021-01-28 |
| Last Update Date | 2021-10-27 |