| NPI | 1861606220 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH 1417) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004991) | 
| Enumeration Date | 2007-05-09 | 
| Last Update Date | 2018-11-30 |