| NPI | 1720426554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.003742) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056044) |
| Enumeration Date | 2013-06-14 |
| Last Update Date | 2015-07-23 |