| NPI | 1740733401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012396) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA190887) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2016-07-29 |
| Last Update Date | 2024-04-29 |