| NPI | 1871133538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085007500) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 61168) |
| 363A00000X Physician Assistant (Licence: WA PA61396344) | |
| Enumeration Date | 2020-01-10 |
| Last Update Date | 2023-06-23 |