| NPI | 1255380796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006182) |
| Additional Taxonomies | 104100000X Social Worker (Licence: MI 6802076513) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2026-05-12 |