| NPI | 1134114606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA2879) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601001109) |
| Enumeration Date | 2005-09-12 |
| Last Update Date | 2010-07-31 |