| NPI | 1659017713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.008676RX) |
| 363AM0700X Physician Assistant, Medical | |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2022-05-10 |
| Last Update Date | 2024-03-04 |