NPI | 1265704845 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 1239) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 1069929) |
Enumeration Date | 2012-01-30 |
Last Update Date | 2021-07-28 |