| NPI | 1649552225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003668) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.008112) |
| Enumeration Date | 2011-09-09 |
| Last Update Date | 2024-11-05 |