| NPI | 1750752762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: GA 9222) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 55-004485) |
| Enumeration Date | 2015-10-16 |
| Last Update Date | 2019-10-07 |