| NPI | 1235550211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50005705RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107722) |
| Enumeration Date | 2013-12-18 |
| Last Update Date | 2020-11-10 |