| NPI | 1225381387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007075) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA 22643) |
| Enumeration Date | 2012-10-25 |
| Last Update Date | 2021-02-22 |