| NPI | 1073728705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.002853) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9104107) |
| 363AM0700X Physician Assistant, Medical (Licence: OH 50.002853) | |
| Enumeration Date | 2007-05-14 |
| Last Update Date | 2013-07-10 |