| NPI | 1164108338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.008244RX) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MT 163552) |
| Enumeration Date | 2023-06-23 |
| Last Update Date | 2025-11-24 |