| NPI | 1215454194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.005193RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH APP-000112838) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50.005193RX) | |
| Enumeration Date | 2017-08-23 |
| Last Update Date | 2023-03-04 |