| NPI | 1386407757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.008592RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 1214500) |
| Enumeration Date | 2024-01-30 |
| Last Update Date | 2024-05-14 |