| NPI | 1023434552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.004003RX) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.004003) |
| Enumeration Date | 2014-03-07 |
| Last Update Date | 2021-06-22 |