| NPI | 1447906490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012657) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11904) |
| Enumeration Date | 2022-02-28 |
| Last Update Date | 2024-11-20 |