| NPI | 1649385972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051218) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50. 001827) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2013-07-16 |