NPI | 1104853662 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9102581) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.001574RX) |
Enumeration Date | 2006-06-28 |
Last Update Date | 2020-05-19 |