| NPI | 1285953588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001003463) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005387) |
| Enumeration Date | 2010-05-26 |
| Last Update Date | 2023-09-27 |