| NPI | 1639571938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50004110) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004110RX) |
| Enumeration Date | 2014-09-18 |
| Last Update Date | 2025-09-05 |