| NPI | 1831132810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MI 6801059465) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2019-10-28 |