| NPI | 1154014793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601011811) |
| Enumeration Date | 2023-05-30 |
| Last Update Date | 2023-08-21 |