| NPI | 1881125540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007583) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601008161) |
| Enumeration Date | 2017-03-24 |
| Last Update Date | 2020-12-23 |