NPI | 1679028591 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011310) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-51613) |
363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-51613) | |
Enumeration Date | 2016-08-20 |
Last Update Date | 2023-03-13 |