| 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 |