| NPI | 1053321075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 1053) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0000621) |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2022-04-07 |