| NPI | 1639527187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007766) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601007766) |
| Enumeration Date | 2016-05-25 |
| Last Update Date | 2016-12-14 |