| NPI | 1174621726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110001422) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 824) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2023-10-04 |