| NPI | 1457896672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.006832RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA55289) |
| 363A00000X Physician Assistant (Licence: AZ 6618) | |
| Enumeration Date | 2016-12-24 |
| Last Update Date | 2021-06-23 |