| NPI | 1134883309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 60359) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601012481) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2021-10-25 |
| Last Update Date | 2024-12-30 |