| NPI | 1134301740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601004591) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601004591) |
| Enumeration Date | 2007-12-05 |
| Last Update Date | 2024-09-07 |