| NPI | 1215647565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA067984) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.007908RX) |
| Enumeration Date | 2022-11-28 |
| Last Update Date | 2026-09-05 |