| NPI | 1871007187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.007378RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2115) |
| Enumeration Date | 2017-11-22 |
| Last Update Date | 2022-08-19 |