| NPI | 1124324421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.003515RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005985) |
| Enumeration Date | 2011-02-03 |
| Last Update Date | 2023-09-01 |