| NPI | 1174828487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.003230RX) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WV 01536) |
| Enumeration Date | 2011-01-18 |
| Last Update Date | 2022-02-02 |