| NPI | 1528149788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MI 5601004522) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MI 5601004522) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2007-07-09 |