| NPI | 1659559185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.002743RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2976) |
| Enumeration Date | 2008-02-06 |
| Last Update Date | 2021-11-30 |