| NPI | 1518919992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002524) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 900) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2018-03-17 |