| NPI | 1891790085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103100) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9103100) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601004445) | |
| 363AS0400X Physician Assistant, Surgical (Licence: MI L5597278) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9103100) | |
| Enumeration Date | 2005-06-15 |
| Last Update Date | 2021-10-01 |