| NPI | 1043612567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007444) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0005540) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2019-10-14 |