| NPI | 1053319590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004196) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C06773) |
| 363A00000X Physician Assistant (Licence: OH 1746) | |
| Enumeration Date | 2005-07-08 |
| Last Update Date | 2020-07-24 |