| NPI | 1457463135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003235) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01046) |
| 363AM0700X Physician Assistant, Medical (Licence: WV 01046) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WV 01046) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2018-12-28 |