| NPI | 1629408935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007724) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: PA 114241) |
| 363A00000X Physician Assistant (Licence: PA MA056589) | |
| Enumeration Date | 2013-11-22 |
| Last Update Date | 2023-10-11 |