| NPI | 1629653639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: OH 50.00896RX) |
| Enumeration Date | 2021-03-11 |
| Last Update Date | 2024-09-13 |