| NPI | 1225434525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008931) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 003243) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 003243) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 003243) | |
| Enumeration Date | 2014-11-13 |
| Last Update Date | 2020-08-25 |