| NPI | 1912283342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106263) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 2890) |
| 363A00000X Physician Assistant (Licence: OH 50.010286RX) | |
| 363A00000X Physician Assistant (Licence: NE 3457) | |
| Enumeration Date | 2011-10-31 |
| Last Update Date | 2026-06-25 |