| NPI | 1124109533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WV 01098) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 01098) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2026-04-30 |