| NPI | 1053347021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 001854) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5315081367) |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2022-01-04 |