| NPI | 1841369642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601001053) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 1821562) |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2021-05-04 |