| NPI | 1730153719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10000584A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.002450) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2021-05-17 |