| NPI | 1710991732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601004953) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4369) |
| 363A00000X Physician Assistant (Licence: OH 50002316) | |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2022-03-18 |