| NPI | 1457934424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7968) |
| Enumeration Date | 2021-04-28 |
| Last Update Date | 2026-03-02 |