NPI | 1053604751 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001013173) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005982) |
363AM0700X Physician Assistant, Medical | |
363AS0400X Physician Assistant, Surgical | |
Enumeration Date | 2011-05-27 |
Last Update Date | 2023-06-21 |