| NPI | 1215997580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02362) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA051953) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50.002527) | |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2011-01-19 |