| NPI | 1245233931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.002717rx) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA003099L) |
| Enumeration Date | 2005-05-27 |
| Last Update Date | 2025-07-31 |