| NPI | 1245412733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006423) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004976) |
| Enumeration Date | 2007-11-27 |
| Last Update Date | 2018-11-26 |