| NPI | 1205819463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50-001030) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30-023439) |
| Enumeration Date | 2005-11-22 |
| Last Update Date | 2011-07-08 |