| NPI | 1578226304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010852) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 032145) |
| Enumeration Date | 2021-10-19 |
| Last Update Date | 2025-09-12 |