| NPI | 1063774172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006342) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 5601006342) |
| Enumeration Date | 2012-06-13 |
| Last Update Date | 2021-02-26 |