| NPI | 1417119736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 01351) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 1351) |
| Enumeration Date | 2008-06-27 |
| Last Update Date | 2025-01-28 |