| NPI | 1043405160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003876) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005108) |
| Enumeration Date | 2007-09-11 |
| Last Update Date | 2012-06-22 |