| NPI | 1942569215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2012012818) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.012265) |
| Enumeration Date | 2012-05-08 |
| Last Update Date | 2026-06-30 |