| NPI | 1508290941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601008345) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA 60397787) |
| 363A00000X Physician Assistant (Licence: GU PA 96) | |
| Enumeration Date | 2013-08-21 |
| Last Update Date | 2025-05-02 |