| NPI | 1104800903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601002234) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3619-23) |
| Enumeration Date | 2005-12-05 |
| Last Update Date | 2016-03-24 |