| NPI | 1396091328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601008760) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 015568) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 015568) | |
| Enumeration Date | 2012-07-27 |
| Last Update Date | 2022-06-06 |