| NPI | 1639707912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2021019987) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 20041100227) |
| Enumeration Date | 2020-03-31 |
| Last Update Date | 2023-03-31 |