| NPI | 1295206134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA1712) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005767RX) |
| Enumeration Date | 2018-12-17 |
| Last Update Date | 2019-02-08 |