| NPI | 1891214300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005171RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7434) |
| Enumeration Date | 2017-09-15 |
| Last Update Date | 2023-05-24 |