| NPI | 1477508901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2118) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601003014) |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2014-07-10 |