| NPI | 1811231194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6172) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 003655) |
| Enumeration Date | 2012-11-27 |
| Last Update Date | 2021-06-17 |