| NPI | 1306410238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062504) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV WV-SE-1781) |
| Enumeration Date | 2021-05-15 |
| Last Update Date | 2024-03-25 |