| NPI | 1578817813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007424) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001468A) |
| Enumeration Date | 2012-11-08 |
| Last Update Date | 2021-02-25 |