| NPI | 1629039847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC PA1989) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.002054) |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50-002054) | |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2022-06-08 |