| NPI | 1003814476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10003719A) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50001592) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 4301090246) | |
| Enumeration Date | 2005-07-11 |
| Last Update Date | 2023-11-02 |