| NPI | 1568702496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006608) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5508) |
| Enumeration Date | 2013-03-01 |
| Last Update Date | 2021-12-09 |