| NPI | 1376008250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 58656) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601009005) |
| Enumeration Date | 2019-02-05 |
| Last Update Date | 2025-05-22 |