| NPI | 1659422384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010017) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MS TPA0012) |
| 363AM0700X Physician Assistant, Medical | |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60030903) | |
| 363AS0400X Physician Assistant, Surgical (Licence: LA PA.200096) | |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2024-10-31 |