| NPI | 1528436425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.006064RX) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT.003963) |
| Enumeration Date | 2015-09-09 |
| Last Update Date | 2022-12-05 |