| NPI | 1790343267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011086) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.005951RX) |
| Enumeration Date | 2019-05-30 |
| Last Update Date | 2022-10-18 |