| NPI | 1720592637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008479) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-11-30 |
| Last Update Date | 2024-10-17 |