| NPI | 1487906285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056784) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601006429) |
| 363AS0400X Physician Assistant, Surgical (Licence: MI 5601006429) | |
| Enumeration Date | 2012-10-04 |
| Last Update Date | 2014-08-12 |