| NPI | 1386070969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OH 50.003872RX) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: OH 003872) |
| Enumeration Date | 2013-09-16 |
| Last Update Date | 2016-11-03 |