| NPI | 1689766941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601004890) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NH 0852) |
| 363AS0400X Physician Assistant, Surgical (Licence: MI 5601004890) | |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2018-12-27 |