| NPI | 1184766776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11864) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004724) |
| Enumeration Date | 2007-02-12 |
| Last Update Date | 2025-09-29 |