| NPI | 1306064142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50-001740) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9104044) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2016-04-05 |