| NPI | 1245118025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15876) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.009637RX) |
| Enumeration Date | 2025-08-21 |
| Last Update Date | 2026-09-30 |