| NPI | 1053838334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117193) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008444) |
| 363A00000X Physician Assistant (Licence: OH 50.005304RX) | |
| 363A00000X Physician Assistant (Licence: MI 5601010975) | |
| Enumeration Date | 2017-08-28 |
| Last Update Date | 2025-01-23 |