| NPI | 1912321027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006923) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 5601006923) |
| Enumeration Date | 2014-02-10 |
| Last Update Date | 2023-03-15 |