| NPI | 1609163609 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601003507) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: MI 5601003507) | |
| Enumeration Date | 2011-06-29 |
| Last Update Date | 2022-09-16 |