| NPI | 1205948452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1900) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50002733) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2008-02-11 |