| NPI | 1346909694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.007809RX) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-12-14 |
| Last Update Date | 2024-12-03 |