| NPI | 1639691256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008297) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2018-03-29 |