| NPI | 1659896744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005167rx) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-10707) |
| Enumeration Date | 2017-08-09 |
| Last Update Date | 2020-11-09 |