| NPI | 1962470807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601001650) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9116040) |
| Enumeration Date | 2006-03-08 |
| Last Update Date | 2023-07-21 |