| NPI | 1598057630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105991) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601006002) |
| Enumeration Date | 2011-05-09 |
| Last Update Date | 2016-03-20 |