| NPI | 1184211146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010615) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-12-24 |
| Last Update Date | 2021-06-21 |