| NPI | 1295134955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11349) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 1823) |
| Enumeration Date | 2014-08-19 |
| Last Update Date | 2022-02-01 |