| NPI | 1043317050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 4217) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601003745) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2019-01-29 |