| NPI | 1205883105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC PA3422) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50001725) |
| Enumeration Date | 2006-05-27 |
| Last Update Date | 2021-08-09 |