| NPI | 1225689847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009505) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601009505) |
| Enumeration Date | 2019-09-25 |
| Last Update Date | 2026-01-12 |