| NPI | 1669767588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004373RX) |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2018-12-10 |