| NPI | 1447213855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0805X (Licence: NC 0010-08986) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50.002432RX) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50002432) | |
| Enumeration Date | 2006-04-07 |
| Last Update Date | 2024-06-03 |