| NPI | 1245410893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.008721RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 1328) |
| Enumeration Date | 2007-11-13 |
| Last Update Date | 2024-04-19 |