| NPI | 1639617673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008917) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004998RX) |
| Enumeration Date | 2017-02-10 |
| Last Update Date | 2023-11-03 |