| NPI | 1962425132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601014011) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085002572) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2026-08-28 |