| NPI | 1972084051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09244) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601008790) |
| Enumeration Date | 2018-08-27 |
| Last Update Date | 2021-05-07 |