| NPI | 1952829343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005786) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: OH LPN.164931.MEDS-IV) |
| 363A00000X Physician Assistant (Licence: OH 50005301RX) | |
| Enumeration Date | 2017-09-06 |
| Last Update Date | 2022-07-21 |