| NPI | 1760109227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601013536) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0011894) |
| Enumeration Date | 2022-10-25 |
| Last Update Date | 2026-01-27 |