| NPI | 1467236364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 56010111989) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601011989) |
| Enumeration Date | 2023-08-22 |
| Last Update Date | 2025-05-16 |