| NPI | 1043355308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 2402) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601003021) |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2016-07-13 |