| NPI | 1588134456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.006802RX) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601008913) |
| Enumeration Date | 2018-12-04 |
| Last Update Date | 2022-08-19 |