| NPI | 1073652335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 00973) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 973) |
| Enumeration Date | 2007-02-05 |
| Last Update Date | 2020-11-10 |