| NPI | 1386744423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601005940) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60203027) |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2015-01-12 |