| NPI | 1134469547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 003739) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 017234) |
| Enumeration Date | 2013-02-21 |
| Last Update Date | 2021-12-27 |