| NPI | 1992704167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601003732) |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2021-06-21 |