| NPI | 1225380629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012837) |
| Additional Taxonomies | 133VN1006X Dietitian, Registered, Nutrition, Metabolic (Licence: WA DI60312524) |
| Enumeration Date | 2012-10-09 |
| Last Update Date | 2025-05-19 |