| NPI | 1003897497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 468) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 862) |
| Enumeration Date | 2005-11-11 |
| Last Update Date | 2023-03-07 |