| NPI | 1528460425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110420) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50-004097) |
| Enumeration Date | 2014-09-23 |
| Last Update Date | 2020-04-23 |