| NPI | 1841018520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 11041) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601012816) |
| Enumeration Date | 2024-10-01 |
| Last Update Date | 2025-06-20 |