| NPI | 1508058009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 01323) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: WV 01323) |
| 363A00000X Physician Assistant (Licence: MD C05465) | |
| Enumeration Date | 2007-08-17 |
| Last Update Date | 2020-07-13 |