| NPI | 1114668928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.007614RX) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-04-05 |
| Last Update Date | 2022-06-15 |