| NPI | 1295953214 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601001417) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601001417) |
| 363A00000X Physician Assistant (Licence: SC 16178) | |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA105856) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA105856) | |
| Enumeration Date | 2007-04-23 |
| Last Update Date | 2011-06-29 |