| NPI | 1942213061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601012193) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AR PA-850) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA00051) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NE 2243) | |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2024-05-03 |