| NPI | 1932624707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.005261RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC715) |
| 363A00000X Physician Assistant (Licence: KY PA2378) | |
| 363AS0400X Physician Assistant, Surgical (Licence: OH 50.005261RX) | |
| Enumeration Date | 2017-08-13 |
| Last Update Date | 2025-07-15 |