| NPI | 1770608465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06096) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI PENDING) |
| Enumeration Date | 2007-03-20 |
| Last Update Date | 2016-01-19 |