| NPI | 1619292109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06567) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.003041) |
| Enumeration Date | 2010-03-29 |
| Last Update Date | 2016-07-11 |