| NPI | 1578001426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011595) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004971RX) |
| Enumeration Date | 2017-02-10 |
| Last Update Date | 2023-03-22 |