| NPI | 1952685497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006372) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 5017) |
| 363AM0700X Physician Assistant Medical (Licence: MI 5601006372) | |
| Enumeration Date | 2011-10-03 |
| Last Update Date | 2022-12-05 |