| NPI | 1124576814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005239RX) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50005239RX) |
| 363AS0400X Physician Assistant, Surgical (Licence: SC 2611) | |
| Enumeration Date | 2016-09-12 |
| Last Update Date | 2020-01-27 |