| NPI | 1487656914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005209RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003244) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2022-01-25 |