| NPI | 1770716300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.003057RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601008780) |
| Enumeration Date | 2009-08-31 |
| Last Update Date | 2019-11-01 |