| NPI | 1629653639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.00896RX) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50.00896RX) | |
| Enumeration Date | 2021-03-11 |
| Last Update Date | 2025-03-31 |