| NPI | 1922088616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110580) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601002022) |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2025-02-14 |