| NPI | 1194709857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.002441) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9101404) |
| Enumeration Date | 2005-12-05 |
| Last Update Date | 2016-01-20 |