| NPI | 1306123112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50003397RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001367A) |
| Enumeration Date | 2011-11-08 |
| Last Update Date | 2018-06-11 |