| NPI | 1740870211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012911) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9244) |
| Enumeration Date | 2021-01-19 |
| Last Update Date | 2025-03-25 |