| NPI | 1518964238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WV 838) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: FL PA9109546) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2018-04-09 |