| NPI | 1093026536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1686) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005796) |
| Enumeration Date | 2010-06-30 |
| Last Update Date | 2013-03-15 |