| NPI | 1508807041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0005541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004763) |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2018-10-02 |