| NPI | 1922380344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2023043647) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085004123) |
| Enumeration Date | 2011-09-12 |
| Last Update Date | 2025-11-10 |