| NPI | 1609928845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010695) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: IL 085001682) |
| Enumeration Date | 2007-01-17 |
| Last Update Date | 2022-09-19 |