| NPI | 1730147919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.001117) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 2540) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2020-05-06 |