| NPI | 1093950297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WV 457) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 880) |
| Enumeration Date | 2008-12-03 |
| Last Update Date | 2015-12-21 |