| NPI | 1831472067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007605) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055110) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA055110) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA055110) | |
| Enumeration Date | 2011-09-23 |
| Last Update Date | 2024-02-21 |