| NPI | 1124348404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11322) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601005764) |
| 363A00000X Physician Assistant (Licence: OH 50.004332RX) | |
| Enumeration Date | 2010-06-09 |
| Last Update Date | 2023-04-11 |