| NPI | 1750752317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601008412) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ME PA1568) |
| Enumeration Date | 2015-10-08 |
| Last Update Date | 2022-03-21 |