| NPI | 1578113171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MI 5601009635) |
| Enumeration Date | 2019-09-16 |
| Last Update Date | 2020-12-09 |