| NPI | 1407296429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006715) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2013-07-05 |
| Last Update Date | 2025-03-04 |