| NPI | 1548244353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 2570) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 1032163) |
| Enumeration Date | 2005-12-05 |
| Last Update Date | 2012-08-30 |