| NPI | 1053776708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NM pa2018-0044) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007593) |
| Enumeration Date | 2015-12-23 |
| Last Update Date | 2024-11-08 |