| NPI | 1023565546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 2005) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0005897) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WV 2005) | |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2023-02-16 |