| NPI | 1982166260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009047) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009245) |
| Enumeration Date | 2019-04-04 |
| Last Update Date | 2025-10-08 |