| NPI | 1396135802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-004850) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2156) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-02-04 |
| Last Update Date | 2021-03-24 |