| NPI | 1184932493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003891) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 01515) |
| Enumeration Date | 2010-09-21 |
| Last Update Date | 2021-12-27 |