| NPI | 1821032566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MI 5601-00-4569) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MI 5601004569) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2021-03-10 |