| NPI | 1568447126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50000714) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 5000714) |
| 363AM0700X Physician Assistant, Medical (Licence: OH 50000714) | |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2011-01-13 |