| NPI | 1285625921 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 508) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 172) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2024-12-03 |