| NPI | 1790657039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601013110) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601013110) |
| Enumeration Date | 2025-09-17 |
| Last Update Date | 2025-09-17 |