| NPI | 1679523567 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 0038487) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OH 50.003432) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2022-09-06 |