| NPI | 1477556215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4138) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 114597) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50001399) | |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2022-02-07 |