| NPI | 1003113671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50003236) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601006019) |
| Enumeration Date | 2011-02-17 |
| Last Update Date | 2023-11-03 |