| NPI | 1417598343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 1168797) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 2401) |
| Enumeration Date | 2019-10-02 |
| Last Update Date | 2022-04-08 |