| NPI | 1790175149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.005352) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001986A) |
| Enumeration Date | 2015-01-23 |
| Last Update Date | 2024-04-03 |