| NPI | 1134884760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010138) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601010704) |
| Enumeration Date | 2021-11-08 |
| Last Update Date | 2024-07-24 |