| NPI | 1023121407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110537) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601002962) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2020-10-15 |