| NPI | 1124301270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006814) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 001003129) |
| Enumeration Date | 2011-09-26 |
| Last Update Date | 2025-09-16 |