| NPI | 1326148115 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051279) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 961) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2025-08-22 |