| NPI | 1497910533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 5415) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WV 01203) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50.002444) | |
| Enumeration Date | 2008-07-28 |
| Last Update Date | 2015-03-06 |