| NPI | 1316415672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.006507RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2180) |
| Enumeration Date | 2018-11-05 |
| Last Update Date | 2024-02-23 |