| NPI | 1477213742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14723) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.008565) |
| 363A00000X Physician Assistant (Licence: OH 50.007151RX) | |
| Enumeration Date | 2021-12-28 |
| Last Update Date | 2024-10-18 |