| NPI | 1730162199 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.008262RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004290) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2023-07-18 |