| NPI | 1831201730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1633) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004815) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2026-03-12 |