| NPI | 1043889769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA061432) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.006486RX) |
| Enumeration Date | 2021-06-18 |
| Last Update Date | 2021-06-18 |