| NPI | 1649887001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012070) |
| Additional Taxonomies | 156F00000X Technician/Technologist |
| Enumeration Date | 2020-09-29 |
| Last Update Date | 2023-11-08 |