| NPI | 1942634837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IL 085007274) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA56810) |
| 363A00000X Physician Assistant (Licence: FL PA9108184) | |
| 363A00000X Physician Assistant (Licence: WI 3187-23) | |
| Enumeration Date | 2013-08-27 |
| Last Update Date | 2026-03-26 |