| NPI | 1255975975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011017) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA7293) |
| Enumeration Date | 2019-11-06 |
| Last Update Date | 2022-04-15 |