| NPI | 1861591836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.002469) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50002469RX) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 53306) | |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2023-03-24 |