| NPI | 1215446331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110674) |
| Enumeration Date | 2017-09-20 |
| Last Update Date | 2023-11-08 |