| NPI | 1790212728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.008487RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601008212) |
| Enumeration Date | 2017-05-22 |
| Last Update Date | 2023-11-21 |