Registry details
Type
Individual
Primary specialty
Physician Assistant
Enumerated
Feb 21, 2019
License(s)
5601008969 (MI), 10002814A (IN)
Addresses on file
| Purpose | Address | City/State | Phone |
|---|---|---|---|
| LOCATION | 304 DETROIT ST | La Porte, IN 46350-2497 | 219-325-3770 |
| MAILING | 304 DETROIT ST | La Porte, IN 46350-2497 | 219-325-3770 |
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