| NPI | 1023574720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14420) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601008986) |
| Enumeration Date | 2019-02-18 |
| Last Update Date | 2026-06-04 |