| NPI | 1386097723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08584) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007855) |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2018-11-05 |