| NPI | 1003055666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601006970) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01677) |
| Enumeration Date | 2009-02-05 |
| Last Update Date | 2014-05-16 |