| NPI | 1700222130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA031637) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50003765) |
| Enumeration Date | 2013-05-13 |
| Last Update Date | 2019-12-12 |