| NPI | 1568844850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50004359) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601012275) |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10004872A) | |
| Enumeration Date | 2015-06-23 |
| Last Update Date | 2025-06-24 |