| NPI | 1326567264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MI 5601008374) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5601008374) |
| Enumeration Date | 2017-09-12 |
| Last Update Date | 2024-10-10 |