| NPI | 1124285184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C04452) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01342) |
| Enumeration Date | 2008-05-19 |
| Last Update Date | 2024-05-21 |