| NPI | 1780969360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OH 50.003955) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 01750) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 5052) | |
| Enumeration Date | 2011-10-14 |
| Last Update Date | 2017-02-27 |