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 |