| NPI | 1215610779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011968) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601011968) |
| Enumeration Date | 2023-08-10 |
| Last Update Date | 2025-04-14 |