| NPI | 1790729143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012774) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA2123) |
| 363A00000X Physician Assistant (Licence: TX PA02728) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA02728) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2024-11-08 |