| NPI | 1386719078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03813) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004866) |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2022-03-12 |