| NPI | 1942767991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MI 5601008945) |
| Enumeration Date | 2019-02-26 |
| Last Update Date | 2019-06-11 |