| NPI | 1467457275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50-00-1016) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50-001016RX) |
| Enumeration Date | 2005-06-17 |
| Last Update Date | 2026-05-19 |