| NPI | 1215297635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MI 5601006319) |
| Enumeration Date | 2012-05-18 |
| Last Update Date | 2021-07-14 |