| NPI | 1083040117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA031175) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.003868) |
| Enumeration Date | 2013-09-20 |
| Last Update Date | 2015-10-14 |