| NPI | 1407305659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 2022) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 2783) |
| Enumeration Date | 2016-09-29 |
| Last Update Date | 2017-02-08 |