| NPI | 1598772071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601005214) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085002270) |
| 363AS0400X Physician Assistant, Surgical (Licence: MI 5601005214) | |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10003974A) | |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2026-06-08 |