| NPI | 1336989284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10005105A) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.008974RX) |
| Enumeration Date | 2024-05-29 |
| Last Update Date | 2025-12-01 |