| NPI | 1477930709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.006435RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA057521) |
| Enumeration Date | 2015-05-06 |
| Last Update Date | 2020-07-10 |