| NPI | 1700475779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010414) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-01-14 |
| Last Update Date | 2022-10-20 |