| NPI | 1003670225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.009644RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA006787) |
| Enumeration Date | 2024-02-08 |
| Last Update Date | 2025-08-26 |