| NPI | 1386311611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 50.007043RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA221860) |
| Enumeration Date | 2021-08-25 |
| Last Update Date | 2025-12-09 |