| NPI | 1255369658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.004755RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020765) |
| 363A00000X Physician Assistant (Licence: MI 5601004156) | |
| 363A00000X Physician Assistant (Licence: NJ 25MP00636600) | |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2025-02-07 |