| NPI | 1558760124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0001060) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007070) |
| 363A00000X Physician Assistant (Licence: MD C0009591) | |
| Enumeration Date | 2014-08-19 |
| Last Update Date | 2025-01-13 |