| NPI | 1417096009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WV 196) |
| Enumeration Date | 2007-02-06 |
| Last Update Date | 2016-05-05 |