| NPI | 1053604751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13173) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005982) |
| Enumeration Date | 2011-05-27 |
| Last Update Date | 2025-08-04 |