| NPI | 1336483205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.003771) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IN 10001473A) |
| Enumeration Date | 2012-11-16 |
| Last Update Date | 2025-09-08 |