| NPI | 1548598667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006085) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001002045) |
| Enumeration Date | 2009-12-01 |
| Last Update Date | 2012-01-04 |