| NPI | 1003245341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006700) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056138) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601006700) | |
| 363A00000X Physician Assistant (Licence: OH 50.004059) | |
| Enumeration Date | 2013-11-07 |
| Last Update Date | 2016-11-16 |