| NPI | 1407535941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.009169RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 15611) |
| Enumeration Date | 2023-07-12 |
| Last Update Date | 2025-12-18 |