| NPI | 1700443512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.007385) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4312) |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2022-02-17 |