| NPI | 1336117969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601002593) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2013-03-20 |