| NPI | 1255662276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005020RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002048) |
| Enumeration Date | 2010-01-15 |
| Last Update Date | 2019-01-08 |