| NPI | 1962927343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009043) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2080) |
| Enumeration Date | 2017-08-07 |
| Last Update Date | 2019-09-11 |