| NPI | 1285017731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.010125RX) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT. 004255) |
| Enumeration Date | 2015-07-01 |
| Last Update Date | 2026-03-13 |