| NPI | 1952810103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009408) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50005325RX) |
| Enumeration Date | 2017-09-20 |
| Last Update Date | 2019-07-12 |