| NPI | 1649673625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA181938) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007191) |
| Enumeration Date | 2014-10-03 |
| Last Update Date | 2022-07-21 |