| NPI | 1932504222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH APP-001012951) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT005119) |
| Enumeration Date | 2014-10-29 |
| Last Update Date | 2025-10-21 |