| NPI | 1851323778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601005653) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110001951) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2012-08-20 |