| NPI | 1265189989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601012691) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL pa9115428) |
| Enumeration Date | 2022-03-02 |
| Last Update Date | 2024-10-28 |