| NPI | 1255829958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005982RX) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: MI 5601008698) | |
| Enumeration Date | 2018-04-27 |
| Last Update Date | 2019-06-07 |