| NPI | 1003005729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-3187) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.002685) |
| Enumeration Date | 2007-10-18 |
| Last Update Date | 2012-01-31 |