| NPI | 1619223096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008106) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MI 5501012935) |
| Enumeration Date | 2012-08-03 |
| Last Update Date | 2017-04-12 |