| NPI | 1578138970 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.009429RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA.61151271) |
| Enumeration Date | 2021-05-26 |
| Last Update Date | 2025-07-15 |