| NPI | 1538701958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50006136RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061928) |
| Enumeration Date | 2019-10-17 |
| Last Update Date | 2021-04-29 |