| 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 |