| NPI | 1518609205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011264) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-04-12 |
| Last Update Date | 2026-04-29 |