| NPI | 1205804150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 845) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: WV 5975) |
| Enumeration Date | 2006-03-08 |
| Last Update Date | 2011-01-05 |