| NPI | 1821309477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007017) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 1426 temp) |
| 363AM0700X Physician Assistant, Medical (Licence: MN 10755) | |
| Enumeration Date | 2010-06-29 |
| Last Update Date | 2015-10-21 |