| NPI | 1417470469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5315226798) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA185145) |
| Enumeration Date | 2017-07-21 |
| Last Update Date | 2021-09-02 |