| NPI | 1013994953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 929) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 202) |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2024-10-30 |