| NPI | 1861240905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.012100) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 137032) |
| Enumeration Date | 2024-05-13 |
| Last Update Date | 2026-02-17 |