| NPI | 1679040943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.005614RX) |
| Enumeration Date | 2018-10-25 |
| Last Update Date | 2025-04-09 |