| NPI | 1245252048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103711) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601002315) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2016-12-07 |