| NPI | 1891400735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601011628) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 56010111628) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50.008035RX) | |
| Enumeration Date | 2023-01-16 |
| Last Update Date | 2025-06-10 |