| NPI | 1962645309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601010250) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0003951) |
| Enumeration Date | 2009-04-15 |
| Last Update Date | 2024-11-06 |