| NPI | 1275781387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 13) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 723) |
| Enumeration Date | 2008-09-03 |
| Last Update Date | 2022-01-12 |