| NPI | 1255412318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50-00-0863) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601002647) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2023-03-07 |