| NPI | 1609127158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006460) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: MI 5601006460) | |
| Enumeration Date | 2012-09-24 |
| Last Update Date | 2022-07-21 |