| NPI | 1336608793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C07533) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2237) |
| Enumeration Date | 2019-03-15 |
| Last Update Date | 2020-04-27 |