| NPI | 1639697980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012063) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5601012063) |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2024-01-16 |