| NPI | 1720597081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.006936RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11498) |
| Enumeration Date | 2017-09-29 |
| Last Update Date | 2021-03-30 |