| 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 |