| NPI | 1154435592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10677) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601002965) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2023-08-22 |