| NPI | 1841619863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 036153537) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-04-08 |
| Last Update Date | 2021-03-15 |