| NPI | 1093270548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.007148RX) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2019-02-08 |
| Last Update Date | 2021-10-01 |