| NPI | 1275040784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5208) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005381RX) |
| Enumeration Date | 2018-01-05 |
| Last Update Date | 2020-12-27 |