| NPI | 1881717023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009476) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106615) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2020-02-10 |