| NPI | 1255671186 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57317) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.003721) |
| Enumeration Date | 2013-03-01 |
| Last Update Date | 2023-01-10 |