| NPI | 1265861025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10002579A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50-003880) |
| Enumeration Date | 2013-11-02 |
| Last Update Date | 2022-03-08 |