| NPI | 1063411023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 584) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06044) |
| Enumeration Date | 2005-07-20 |
| Last Update Date | 2019-06-03 |