| NPI | 1992298681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011897) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 23.004110) |
| Enumeration Date | 2018-06-07 |
| Last Update Date | 2024-04-22 |