| NPI | 1528573110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010059) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CO PA.0005274) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-12-05 |
| Last Update Date | 2021-01-13 |