| NPI | 1821793134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012962) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-04-04 |
| Last Update Date | 2025-01-20 |