| NPI | 1902258197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.009842RX) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT005470) |
| Enumeration Date | 2016-07-12 |
| Last Update Date | 2026-03-12 |