| NPI | 1821426362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.003912) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 617) |
| Enumeration Date | 2013-10-18 |
| Last Update Date | 2017-02-10 |