| NPI | 1134715923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.006569RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC995) |
| Enumeration Date | 2020-12-15 |
| Last Update Date | 2023-06-09 |