| NPI | 1508806340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA000147L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01229) |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2018-06-28 |