| NPI | 1841632072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006973) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA056178) |
| Enumeration Date | 2013-07-30 |
| Last Update Date | 2014-08-01 |