| NPI | 1679587661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601003342) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA759) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2021-09-10 |