| NPI | 1316619414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 60610) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 60610) |
| 363A00000X Physician Assistant (Licence: MI 5601010851) | |
| 363AM0700X Physician Assistant, Medical (Licence: CA 60610) | |
| Enumeration Date | 2021-09-28 |
| Last Update Date | 2022-03-21 |