| NPI | 1821533712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.006407RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA54121) |
| Enumeration Date | 2016-12-30 |
| Last Update Date | 2021-07-13 |