| NPI | 1952742603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006701) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5601006701) |
| Enumeration Date | 2013-07-10 |
| Last Update Date | 2021-04-13 |