| NPI | 1376008136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 2314) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005641RX) |
| Enumeration Date | 2019-02-06 |
| Last Update Date | 2024-01-22 |