| NPI | 1346595782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601006488) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.009916RX) |
| 363A00000X Physician Assistant (Licence: WI 8214-23) | |
| 146N00000X Emergency Medical Technician, Basic (Licence: MI 3203040182) | |
| Enumeration Date | 2012-07-23 |
| Last Update Date | 2025-12-04 |