| NPI | 1811942196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05923) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50001332) |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2021-03-18 |