| NPI | 1962470583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601003033) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9111791) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2019-02-28 |