| NPI | 1831631514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MI 5601007974) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MI 5601007974) |
| Enumeration Date | 2016-11-10 |
| Last Update Date | 2021-04-09 |