| NPI | 1467632505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 909) |
| Enumeration Date | 2007-11-06 |
| Last Update Date | 2012-08-27 |