| NPI | 1851802243 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005332RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601011558) |
| Enumeration Date | 2017-10-12 |
| Last Update Date | 2023-08-17 |