| NPI | 1700144664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007721) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2012-04-30 |
| Last Update Date | 2017-03-22 |