| NPI | 1205837598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50002436) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC A839) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2013-04-03 |