| NPI | 1881139996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012186) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4840) |
| 363A00000X Physician Assistant (Licence: FL PA9110046) | |
| Enumeration Date | 2016-12-28 |
| Last Update Date | 2026-04-01 |