NPI | 1760992663 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.005399RX) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601008321) |
Enumeration Date | 2017-10-05 |
Last Update Date | 2023-11-03 |