| NPI | 1164877320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601007759) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2016-04-25 |
| Last Update Date | 2017-02-16 |