| NPI | 1174520662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OH 50001501) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601003429) |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2023-11-03 |