| NPI | 1023208105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601004979) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.003692RX) |
| Enumeration Date | 2007-07-26 |
| Last Update Date | 2023-01-03 |