| NPI | 1962588897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 11548) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50001829) |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2014-10-06 |