| NPI | 1326440413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9108216) |
| Enumeration Date | 2014-09-19 |
| Last Update Date | 2025-11-14 |