| NPI | 1982616249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 6403) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601003169) |
| 363A00000X Physician Assistant (Licence: MI 003169) | |
| Enumeration Date | 2006-08-13 |
| Last Update Date | 2019-08-05 |