| NPI | 1447901665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15439) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2726) |
| Enumeration Date | 2022-01-11 |
| Last Update Date | 2026-04-29 |