| NPI | 1306823802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.003797RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS PA074) |
| Enumeration Date | 2005-12-27 |
| Last Update Date | 2018-09-06 |