| NPI | 1114122728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601005425) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3631) |
| Enumeration Date | 2007-06-15 |
| Last Update Date | 2019-02-07 |