| NPI | 1982703625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.001563) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601003798) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2007-07-08 |