| NPI | 1366724650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1074) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50.003314) |
| Enumeration Date | 2011-09-13 |
| Last Update Date | 2019-02-10 |