| NPI | 1790904456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110002002) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601001523) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2007-07-08 |