| NPI | 1538166616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601004701) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50002129) |
| Enumeration Date | 2005-07-05 |
| Last Update Date | 2017-07-27 |