| NPI | 1336928977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601013917) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009785) |
| Enumeration Date | 2023-09-25 |
| Last Update Date | 2026-07-01 |