| NPI | 1760924013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.006783RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11244) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA11244) | |
| Enumeration Date | 2016-11-16 |
| Last Update Date | 2023-10-10 |