| NPI | 1336140896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50-000768) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50-00-0768) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2020-12-29 |