| NPI | 1790076537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008868) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 7947809-1206) |
| Enumeration Date | 2011-04-27 |
| Last Update Date | 2019-06-13 |