| NPI | 1053318378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50001411) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0008181) |
| Enumeration Date | 2005-07-01 |
| Last Update Date | 2025-07-02 |