| NPI | 1750685335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006199) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 3145) |
| Enumeration Date | 2010-12-22 |
| Last Update Date | 2012-03-14 |