Registry details
Type
Individual
Primary specialty
Physician Assistant
Enumerated
Jan 10, 2007
License(s)
5601003061 (MI), 085003646 (IL)
Addresses on file
| Purpose | Address | City/State | Phone |
|---|---|---|---|
| MAILING | 400 KIRK DR | Mt Zion, IL 62549-1612 | 269-655-4084 |
| LOCATION | 3131 N WATER ST | Decatur, IL 62526-2472 | 217-876-5320 |
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