| NPI | 1568558898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50-00-1571) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601004340) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2016-11-01 |