| NPI | 1659929123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115985) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601010457) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2019-08-28 |
| Last Update Date | 2022-11-09 |