| NPI | 1386622835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 1197) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50002345) |
| Enumeration Date | 2006-01-05 |
| Last Update Date | 2015-02-09 |