| NPI | 1558813394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.010323RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA2088) |
| Enumeration Date | 2016-10-27 |
| Last Update Date | 2026-06-09 |