| NPI | 1033494299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006661) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA3326) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA3326) | |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2021-02-24 |