| NPI | 1205336823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: 5601008661) |
| Additional Taxonomies | 225X00000X Occupational Therapist (Licence: MI 5201008637) |
| Enumeration Date | 2018-02-20 |
| Last Update Date | 2023-01-02 |