| NPI | 1205508215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601010605) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601010605) |
| Enumeration Date | 2021-09-29 |
| Last Update Date | 2022-02-17 |