| NPI | 1013955616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.001928RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10000630A) |
| Enumeration Date | 2006-06-04 |
| Last Update Date | 2023-03-30 |