| NPI | 1134608052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0006479) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005677RX) |
| Enumeration Date | 2018-08-10 |
| Last Update Date | 2021-01-14 |