| NPI | 1447769617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9111394) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601008404) |
| Enumeration Date | 2017-09-20 |
| Last Update Date | 2026-08-24 |