| NPI | 1487818167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 01390) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WV TEMPORARY) |
| Enumeration Date | 2008-07-11 |
| Last Update Date | 2009-12-30 |