| NPI | 1134407133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12541) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.003359) |
| Enumeration Date | 2011-07-26 |
| Last Update Date | 2022-10-14 |