| NPI | 1518475730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008544) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4400) |
| Enumeration Date | 2018-01-22 |
| Last Update Date | 2022-07-20 |