| NPI | 1063452266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.000812RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA pa13591) |
| 363A00000X Physician Assistant (Licence: OH 50.000812) | |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2023-09-20 |