| NPI | 1730849779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.007559RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601010625) |
| Enumeration Date | 2021-12-17 |
| Last Update Date | 2025-03-10 |