| NPI | 1063961092 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009969) |
| Additional Taxonomies | 225400000X Rehabilitation Practitioner |
| Enumeration Date | 2016-10-03 |
| Last Update Date | 2020-08-20 |