| NPI | 1093489379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 2549) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN pending) |
| Enumeration Date | 2021-08-02 |
| Last Update Date | 2025-07-22 |