| NPI | 1104124007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 5079) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 56001005935) |
| Enumeration Date | 2011-03-02 |
| Last Update Date | 2019-07-25 |