| NPI | 1760581383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601002665) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012350) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2018-11-15 |