| NPI | 1992866784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601005545) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0002740) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601005545) | |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2013-04-11 |