| NPI | 1922732908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 127594) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.008564RX) |
| Enumeration Date | 2022-07-14 |
| Last Update Date | 2024-09-30 |