| NPI | 1770058182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.008642RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA060214) |
| Enumeration Date | 2018-10-11 |
| Last Update Date | 2024-10-05 |