| NPI | 1740611557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: OH 50.007428RX) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: WA PA60755013) |
| Enumeration Date | 2013-12-03 |
| Last Update Date | 2025-08-26 |