| NPI | 1215211628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11286) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601006195) |
| Enumeration Date | 2011-10-04 |
| Last Update Date | 2025-04-22 |