| NPI | 1730471368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006017) |
| Additional Taxonomies | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2011-05-16 |
| Last Update Date | 2015-10-09 |