| NPI | 1407405681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009737) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-09-10 |
| Last Update Date | 2022-10-20 |