| NPI | 1194752014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA200592) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004311) |
| Enumeration Date | 2006-06-27 |
| Last Update Date | 2020-12-07 |