| NPI | 1063531960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601002467) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: MI 5601002467) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601002467) | |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2022-10-07 |