| NPI | 1861490831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MI 5601002855) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50001098) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2008-04-29 |