| NPI | 1376751040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010025) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 009421-1) |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10004993A) | |
| 363A00000X Physician Assistant (Licence: FL PA9109479) | |
| Enumeration Date | 2007-05-18 |
| Last Update Date | 2025-10-01 |