| NPI | 1295107308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601007667) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.009869RX) |
| Enumeration Date | 2015-10-28 |
| Last Update Date | 2026-01-02 |